Edited by: Oswald David Kothgassner, Medical University of Vienna, Austria
Reviewed by: Corinna Isensee, University Medical Center Göttingen, Germany; Mira Chavanon, University of Marburg, Germany
†These authors have contributed equally to this work and share first authorship
‡ORCID: Anna Perez,
This article was submitted to Developmental Psychology, a section of the journal Frontiers in Psychology
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The SARS-COVID-19 pandemic and its associated disease control restrictions have in multiple ways affected families with young children, who may be especially vulnerable to mental health problems. Studies report an increase in perinatal parental distress as well as symptoms of anxiety or depression in children during the pandemic. Currently, little is known about the impact of the pandemic on infants and their development. Infant regulatory problems (RPs) have been identified as early indicators of child socio-emotional development, strongly associated with maternal mental health and the early parent–infant interaction. Our study investigates whether early parenthood under COVID-19 is associated with more maternal depressive symptoms and with a perception of their infants as having more RPs regarding crying/fussing, sleeping, or eating, compared to mothers assessed before the pandemic.
As part of a longitudinal study, 65 women who had given birth during the first nationwide disease control restrictions in Northern Germany, were surveyed at 7 months postpartum and compared to 97 women assessed before the pandemic. RPs and on maternal depressive symptoms were assessed by maternal report. Number of previous children, infant negative emotionality, and perceived social support were assessed as control variables.
Compared to the control cohort, infants born during the COVID-19 pandemic and those of mothers with higher depressive symptoms were perceived as having more sleeping and crying, but not more eating problems. Regression-based analyses showed no additional moderating effect of parenthood under COVID-19 on the association of depressive symptoms with RPs. Infant negative emotionality was positively, and number of previous children was negatively associated with RPs.
Due to the small sample size and cross-sectional assessment, the possibility for more complex multivariate analysis was limited. The use of parent-report questionnaires to assess infant RPs can support but not replace clinical diagnosis.
The pandemic conditions affecting everyday life may have a long-term influence on impaired infant self- and maternal co-regulation and on maternal mental health. This should be addressed in peripartum and pediatric care. Qualitative and longitudinal studies focusing on long-term parental and infant outcomes under ongoing pandemic conditions are encouraged.
The ongoing SARS-CoV-2 pandemic has had profound global effects on economy, healthcare systems, and societal structures (
The changed conditions many families face under COVID-19 restrictions may negatively affect their everyday life and exacerbate the dynamics between maternal psychological distress and infant emotional and behavioral problems, particularly in families with preexisting risk factors (
Regulatory problems (RPs) such as excessive infant crying, sleeping or eating problems show the strongest prevalence rates in young infants up to 18 months (
According to the clinical classification system DC: 0–5, infants are diagnosed with primary “Sleep, Eating and Crying Disorders,” if the functioning of the infant, family, or both, is persistently impaired, and other diagnoses such as a sensory processing disorder are ruled out (
In the first years of life, infants are especially vulnerable to an unfavorable environment and dysfunctional family dynamics due to their strong dependency on their caregivers and to rapid brain and behavioral development (
In the literature, perinatal maternal depression was – individually and in comorbidity with anxiety – associated with excessive infant crying and sleeping problems (
The pandemic as an early familial stressful experience with the potential to affect birth, postpartum socio-emotional wellbeing, and the parental ability to co-regulate the baby, may be also associated with unfavorable regulatory outcomes in early infancy. Exposure to stressors can lead to cognitive, emotional and physical fatigue in parents which in turn may strain the parent–child relationship (
Several studies indicated an increased risk for postpartum depression in mothers who delivered their babies during the pandemic (
In Hamburg, Germany, COVID-19 related disease control regulations led in March 2020 to the closing of schools and kindergartens, cultural, sport, and recreational facilities, substantial contact restrictions in the public and private domain, along with official recommendations for remote working from home, whenever possible. These restrictions were partially eased during summer 2020 and reinforced with a nationwide lockdown in November 2020. Schools and kindergartens were then reopened in August 2020, mostly part-time enforcing strong hygiene and social distance regulations. Hence, the second wave of the pandemic beginning in autumn 2020 (
Our study aimed to assess both aspects, infant RPs regarding crying/fussing, eating, and sleeping, and maternal depressive symptoms in the context of parenthood under COVID-19 conditions, compared to a sample of mother–child dyads assessed before the worldwide outbreak of SARS-CoV-2. We expected that the pandemic-related difficulties parents might experience within the first 7 months postpartum may lead to more maternal depressive symptoms and more infant RPs in families during COVID-19 and that the association of maternal depressive symptoms with infant RPs would be stronger in the COVID-19 than in the control cohort.
Moreover, infant negative emotionality, maternal perceived social support, and number of previous children were also considered due to their potential influence on RPs. Specifically, more difficult infant temperament and lower social support reported by the mother have been previously linked with more infant RPs (
In a previous analysis, slightly higher levels of generalized anxiety were found in the COVID-19 cohort at 3 weeks postpartum, compared to the control cohort (
As part of a longitudinal study on parental mental health and infant socio-emotional development and adjustment under the ongoing SARS-CoV-2 pandemic, maternal reports on sociodemographic and obstetric background, psychological and infant variables were assessed at 3 weeks (T1) and again at 6 to 7 (T2) and 12 months (T3) postpartum. All participants of the COVID-19 cohort had given birth at the University Medical Center Hamburg-Eppendorf between March 15th and May 1st, 2020, i.e., within the first 6 weeks of the nationwide disease control restrictions in the federal state of Hamburg. The control cohort comprised a population-based prospective longitudinal pregnancy study sample at the same institution (PAULINE – “Prenatal Anxiety and Infant Early Emotional Development”) who had participated under pre-pandemic conditions (
Participants of the control cohort were recruited upon initial presentation for their birth registration at the University Medical Center in the third trimester of pregnancy. For the COVID-19 cohort, eligible women were recruited 3–8 weeks after their hospital discharge via personal phone call based on contact information from admission charts. For both cohorts, the same set of self-report questionnaires were sent out by post. Of the 90 women in the COVID-19 cohort who participated at 3 weeks postpartum, 65 responded at 6–7 months postpartum (72.2%). In the control cohort, data of 97 (101 participants at T1 corresponding to 96.0%) participants was available at 6–7 months postpartum. The higher dropout rate in the COVID-19 cohort could be related to the varied study setting with no direct personal contact with the study team due to the prevailing circumstances of the pandemic. Additionally, a habituation effect toward the pandemic-related restrictions over time may have also reduced interest in further study participation.
Regulatory problems based on parent report with reference to a typical week in the family’s life were assessed with the Questionnaire for Crying, Feeding, and Sleeping (German: Fragebogen zum Schreien, Füttern, Schlafen, SFS;
Maternal level of depressive symptoms during the past 7 days was assessed with the Edinburgh Postnatal Depression Scale (EPDS;
Infant negative emotionality was measured with the Infant Behavior Questionnaire (IBQ;
Perceived social support on an emotional and instrumental level was assessed with a subscale of the Berlin Social Support Scale (BSSS;
As part of an explorative analysis, generalized anxiety was assessed with the Generalized Anxiety Disorder Scale (GAD-7;
First, descriptive statistics of the continuous variables (mean, standard deviation, and range) and bivariate correlations were investigated. Group differences for relevant variables were reported based on univariate ANOVA, Mann–Whitney-
Characteristics of the final sample included in this analysis are listed in
Characteristics of the sample.
PAULINE |
PAULINE-COVID-19 |
|
( |
( |
|
Maternal age at T1 (years), |
34.51 (3.25) | 36.02 (4.55) |
No degree | 1 (1) | 0 (0.0) |
Main or middle school | 4 (4.1) | 6 (9.3) |
High school graduation | 18 (18.6) | 5 (7.7) |
University degree | 68 (70.1) | 51 (78.5) |
Information not provided | 6 (6.2) | 3 (4.6) |
≤1,000 € | 2 (2.0) | 1 (1.5) |
1,001–2000 € | 8 (8.3) | 3 (4.6) |
2,001–4,000 € | 24 (24.8) | 14 (21.6) |
≥4,001 € | 59 (60.9) | 46 (70.8) |
Information not provided | 5 (5.2) | 1 (1.5) |
Number of previous children, |
1.49 (0.58) | 1.64 (0.74) |
Girl | 35 (36.1) | 29 (44.6) |
Boy | 61 (62.9) | 35 (53.8) |
Information not provided | 1 (1.5) | 1 (1.5) |
Exclusive breastfeeding | 15 (15.5) | 12 (18.5) |
Partial breastfeeding | 48 (49.5) | 40 (61.5) |
Not breastfeeding | 24 (24.7) | 13 (20.0) |
Information not provided | 10 (10.3) | – |
Descriptive statistics of the included psychometric variables for the main analyses.
COVID-19 ( |
PAULINE ( |
η2 | |||||||||
Min | Max | Min | Max | ||||||||
RPs with sleeping/crying (SFS) | 1.80 | 0.41 | 1.09 | 2.75 | 1.61 | 0.33 | 1.04 | 2.50 | 9.77 | 0.002 | 0.06 |
RPs with eating/feeding (SFS) | 1.24 | 0.27 | 1.00 | 2.46 | 1.21 | 0.32 | 1.00 | 2.46 | 0.29 | 0.594 | 0.00 |
Maternal depressive symptoms (EPDS) | 6.25 | 4.48 | 0 | 20.00 | 5.05 | 4.37 | 0 | 25.00 | 4.03 | 0.046 | 0.03 |
Infant negative emotionality (IBQ) | 3.12 | 0.58 | 2.04 | 4.72 | 2.95 | 0.59 | 1.89 | 4.53 | 0.38 | 0.538 | 0.00 |
Maternal perceived social support (BSSS) | 3.86 | 0.28 | 2.80 | 4.00 | 3.80 | 0.35 | 2.40 | 4.00 | 1.04 | 0.308 | 0.01 |
Significant bivariate zero-order correlations (
Bivariate correlations of the included variables.
1 | 2 | 3 | 4 | 5 | 6 | 7 | ||
(1) | RPs with sleeping/crying (SFS) | – | 0.29 |
0.25 |
0.33 |
–0.16 | 0.52 |
−0.25 |
(2) | RPs with eating/feeding (SFS) | – | –0.04 | 0.18 |
–0.02 | 0.44 |
−0.22 |
|
(3) | Cohort |
– | 0.16 |
0.11 | 0.05 | –0.08 | ||
(4) | Maternal depressive symptoms (EPDS) | – | –0.06 | 0.14 | −0.34 |
|||
(5) | Number of previous children | – | –0.02 | 0.02 | ||||
(6) | Infant negative emotionality (IBQ) | – | –0.12 | |||||
(7) | Maternal perceived social support (BSSS) | – |
First, the interactive effect of cohort affiliation and depressive symptoms on infant RPs in the context of crying/sleeping was investigated, after controlling for number of previous children, infant negative emotionality and perceived social support. Moderation analysis did not show a significant relevance of being in the COVID-19 or control cohort for the association between depressive symptoms and infant RPs in the context of crying/sleeping
Main effects for the associations of infant RPs with the included variables (
RPs with sleeping/crying |
RPs with eating/feeding |
|||||||||
95% CI | 95% CI | |||||||||
Constant | 1.76 | 0.06 | 0.001 | [1.65, 1.88] | 0.85 | 1.22 | 0.06 | 0.001 | [1.11, 1.33] | 0.73 |
Cohort |
0.15 | 0.05 | 0.003 | [0.06, 0.25] | 0.06 | 0.05 | 0.04 | 0.186 | [−0.03, 0.13] | 0.01 |
Maternal depressive symptoms (EPDS) | 0.02 | 0.01 | 0.006 | [0.01, 0.03] | 0.05 | 0.01 | 0.01 | 0.204 | [−0.00, 0.02] | 0.01 |
Number previous children | –0.09 | 0.04 | 0.013 | [−0.16, −0.02] | 0.04 | 0.01 | 0.03 | 0.796 | [−0.05, 0.07] | 0.00 |
Infant negative emotionality (IBQ) | 0.01 | 0.00 | 0.001 | [0.01, 0.02] | 0.26 | 0.01 | 0.00 | 0.001 | [0.00, 0.01] | 0.18 |
Maternal perceived social support (BSSS) | –0.13 | 0.07 | 0.078 | [−0.29, 0.01] | 0.02 | –0.15 | 0.09 | 0.104 | [−0.34, 0.04] | 0.03 |
Second, the interaction effect of the cohort affiliation and maternal depressive symptoms on infant RPs in the context of eating problems was investigated. Again, there was no significant cohort effect on the association between depressive symptoms and infant RPs regarding infant eating/feeding,
In a previous analysis, the COVID-19 cohort reported slightly but significantly higher levels of generalized anxiety compared to the control group at 3 weeks postpartum (
Finally, a potential effect of current breastfeeding status on infant RPs was explored. An interaction between belonging to the COVID-19 cohort and breastfeeding (0 = not breastfeeding, 1 = exclusively or partly breastfeeding) was not found for RPs regarding infant crying/sleeping,
Results in the main and explorative analyses were confirmed when (a) only participants without missing data were included (
This study aimed to assess infant RPs regarding crying/fussing, eating, and sleeping as well as maternal depressive symptoms in the context of parenthood under COVID-19 conditions, compared to a sample of mother–child dyads assessed before the worldwide outbreak of SARS-CoV-2. Additionally, a potential effect of generalized anxiety and of breastfeeding status on infant outcome was explored.
Mothers in the COVID-19 group and those with higher depressive symptoms reported more infant RPs regarding crying and sleeping than mothers in the control cohort. However, the association of depressive symptoms with infant RPs was not stronger in the COVID-19 group compared to the control group. This finding suggests that the observed independent effect of pandemic conditions on infant regulatory behavior may be explained by other aspects not analyzed in the current study. A potential mediator for this association is maternal pandemic-induced stress, as the imposed restriction measures affected multiple domains of families’ everyday life. In line with this, a recently published longitudinal study from Italy showed that the association of infants’ regulatory capacity at 3 months with maternal postnatal anxiety was mediated by parenting stress (
Compared to the control cohort, more mothers in the COVID-19 cohort reported depressive symptom levels above the cut-off values indicative of mild depressive disorders. This observation is in line with the findings of several studies, who reported more depressive symptoms (
Maternal symptoms of depression were associated with more infant crying and/or sleeping problems in the current study. Maternal or parental depressive and anxiety disorders have been identified as predictors of infant RPs before, with evidence for specific effects of parental mental health symptoms on infant RPs. In a prospective longitudinal study excessive infant crying was specifically associated with maternal anxiety disorders, while infant sleeping problems were related to maternal depressive symptoms (
Certain infant characteristics attributed to infant negative emotionality are often found in association with RPs, such as increased excitability, high activity level, lack of adaptability, and impaired self-soothing ability (
In both cohorts, women who had given birth to their first child reported more crying and sleeping problems. This may be due to a higher level of uncertainty and lack of experience in taking care of the new infant (
The current findings support the association between perceived crying/fussing and sleeping RPs and maternal depressive symptoms as reported by the participants themselves via questionnaire. In contrast to previous research (
Perceived social support had no influence on infant RPs.
Most (80%) of the mothers in the COVID-19 group were still breastfeeding their infants at 6–7 months of age, significantly more than in the control group. This is in line with a cross-sectional study reporting a higher rate of exclusive breastfeeding (82%) than typically observed among Australian women (
The main strength of this investigation is the direct comparison of mothers of young infants during COVID-19 and under pre-pandemic conditions, implementing the same psychometric instruments at the same institution. However, there are several limitations to consider. Due to the modest sample size and the cross-sectional assessment, the possibility for more complex multivariate analysis was limited. The use of parent-report questionnaires to assess maternal symptoms of depression and infant RPs can support but not replace clinical interviews and diagnoses. A selection bias cannot be ruled out, as it was the participants’ own responsibility to return the questionnaires, especially in the COVID-19 cohort, which was less closely connected with the study team. It can further not be ruled out that an attrition bias may influence variance in the reported variables. Moreover, the relatively homogenous SES and the primary exclusion of infant complications may result in overseeing families with more socio-economic or medical constraints during the pandemic (
Overall, our results suggest that the pandemic conditions affecting multiple domains of families’ everyday life may have consequences for mothers’ mental health, maternal perception of impaired infant self-regulation and maternal co-regulation, and should be addressed in current postpartum maternal and pediatric care. Qualitative and longitudinal studies focusing on transient and long-term parental and infant outcomes under ongoing pandemic conditions are encouraged.
The datasets presented in this article are not readily available because of the ethical committee’s decision. Requests to access the datasets should be directed to
The studies involving human participants were reviewed and approved by the Ethik-Kommission der Ärztekammer Hamburg. The patients/participants provided their written informed consent to participate in this study.
AP: study conceptualization, participant recruitment, data acquisition, investigation, and writing original draft. AG: conceptualization, methodology, formal analysis, and writing original draft. LS and SS: investigation, data curation, and writing original draft. DS: revision original draft and resources. CB: revision original draft, resources, and funding. SM: conceptualization, investigation, methodology, writing original draft, supervision, project administration, and funding. All authors contributed to the article and approved the submitted version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
This work was supported by the Georg & Jürgen Rickertsen Stiftung and the Jürgen Rickertsen Stiftung. SS received a fellowship grant from the University Medical Center Hamburg-Eppendorf.
The authors would like to thank all the participants for allowing us to study them during the peripartum period.
The Supplementary Material for this article can be found online at: